DRG Coder
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Job Description
Senior DRG Coder reviewing inpatient medical records and assigning diagnosis codes. Collaborating with various teams to ensure compliance and accuracy in coding and reimbursement processes.
Responsibilities:
- Review inpatient hospital records and assign accurate diagnosis and procedure codes
- Determine the appropriate MS-DRG or APR-DRG assignment based on coding and clinical documentation
- Conduct coding validation and auditing to ensure compliance with payer and regulatory requirements
- Identify documentation gaps and communicate opportunities to providers, hospitals, and Clinical Documentation Improvement (CDI) teams
- Analyze denials and underpayments related to coding and DRG assignment
- Support retrospective and concurrent reviews of high-cost admissions and outlier cases
- Collaborate with utilization management, case management, finance, and contracting teams to optimize reimbursement and cost containment
- Assist with internal and external audits, including RAC, Medicare Advantage, Medicaid, and commercial payer reviews
- Provide education and mentoring to coding staff and other stakeholders
- Monitor changes in coding guidelines, reimbursement methodologies, and regulatory requirements
- Prepare reports and summaries related to coding accuracy, financial impact, and audit findings
- Maintain confidentiality and compliance with HIPAA and company policies
- Other duties as assigned
Requirements:
- Associate’s degree in Health Information Management, Nursing, or related field
- Minimum of 5 years of inpatient coding experience
- Minimum of 2 years of advanced DRG validation, auditing, or hospital reimbursement experience
- Certifications One or more of the following required: • CCS, RHIA, or RHIT from American Health Information Management Association • CIC or CPC from AAPC
- Have advanced knowledge of ICD-10-CM, ICD-10-PCS, MS-DRG, and APR-DRG methodologies
- Proficiency in coding software, electronic medical records, and Microsoft Office applications
- You're great for the role if:
- Experience working with Medicare Advantage, Medicaid, and commercial health plans
- Experience in a delegated IPA, MSO, or managed care environment
- Have a strong understanding of Medicare reimbursement and payer audit processes
- Ability to interpret complex clinical documentation
- Knowledge of utilization management, case management, and managed care operations
- Strong analytical, organizational, and problem-solving skills
- Ability to work independently and manage multiple priorities
- Excellent written and verbal communication skills.
Benefits:
- This position is remotely based in the U.S. The home office is located at 600 City Parkway West 10th Floor, Orange, CA 92868.
- This role is required to attend occasional in-person meetings with internal departments and external providers/hospitals, training, or audit purposes.
- The national target pay range for this role is between $33.00 - $38.00. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.
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